Emergency Dermatology

Dr Melissa Barkham

Spotlight Seminar 30th September 2010

Why is this important?

Urgent recognition and treatment of dermatologic emergencies can be life saving and prevent long term morbidity

How do you differentiate rare life threatening conditions from the common skin complaints that make up 10 - 20% of consultations in primary care?

Skin structure and function

Protective barrier (toxins, microbes, u.v. light, physical injury)

Temperature regulation Fluid homeostasis Sensation Immunological function Synthetic

(e.g. Vitamin D) Psycho-social

Consequences of Skin failure

Similar to patients with extensive burns

DehydrationFluid and electrolyte imbalanceHypo - albuminaemiaHypotensionHypothermiaSepsisOther organ failure (e.g. renal, hepatic, CCF)

Emergency Dermatology Overview

Skin signs a diagnostic clue (to serious underlying disorder)

Severe Infections (e.g. meningococcaemia, necrotising facsiitis, staphylococcal scalded skin)

Acute autoimmune disease(e.g. SLE, systemic vasculitis)

Paraneoplastic(e.g. dermatomyositis)

Skin disease causing risk of vital organ failure / death

Severe adverse drug reactions (e.g. toxic epidermal necrolysis)

Erythroderma(e.g. due to extensive inflammatory skin disease )

Autoimmune Blistering disorders (e.g. pemphigus vulgaris)

Team approach

GP Accident and emergency On call medical

(or paediatric) teamDermatology consultants and

specialist nurses ITU HistopathologyMicrobiology…..to name but a few

Cutaneous Adverse Drug Reactions

Common - severity variableCan be life threatening Potential long term sequelae

(e.g. blindness)Think carefully before you

prescribe any medicine!Yellow card reporting (MHRA)Over the counter drugs and

supplements can be the culprit

Cutaneous Adverse Drug Reactions

History may not be volunteered

Ask about all medications taken in the last 3 months

Prescribed and non prescribed (including household remedies, herbal remedies, vitamins and supplements)

Beware compound preparations (e.g. cold and flu remedies)

Severe Drug reaction - types

Exanthemous (morbilliform) Stevens - Johnson Syndrome

(SJS) and Toxic Epidermal Necrolysis (TEN)

Drug hypersensitivity syndrome (DHS)

Urticaria +/- angioedema

Drug reaction - warning signs

Facial or mucous membrane involvement

Widespread erythemaSkin painBlistering / skin necrosisFeverLymphadenopathy / arthralgiaFeatures of anaphylaxisOther organ involvement

(e.g. hepatic or renal dysfunction)

Exanthemous drug reaction - features

Commonest typeOnset 5-10 days after new drug Morbilliform (measles like)

maculopapular rashUsually itchySometimes associated with fever / malaiseCommoner in patients with infectious

mononucleosis, leukaemia or HIVSuspected drug (or drugs) should be

discontinued and rash subsides in 1-2 weeks

Exanthemous drug eruption - culprits

PenicillinsCarbamazepineAllopurinolSulphonamidesNSAIDSPhenytoin Isoniazid

DHS - clinical features

Morbilliform rash with fever and internal organ involvement

“Toxic erythema”Mortality - about 10%Later onset (2-6 weeks) after new drug

commencedFever, lymphadenopathyEosinophilia (DRESS) in someHepatic / renal failureTreatment: withdrawal of offending

drug(s) and supportive care

DHS - culprits

SulphonamidesDapsoneAnticonvulsantsACE inhibitorsBeta - blockersAllopurinolMinocyclineSSRI

TEN / SJS - clinical features

Rare drug reaction - presents with skin and mucosal loss

Variants of the same condition (differentiated by extent of skin involved - TEN >30%, SJS <10%)

Mortality - 50%Mucous membrane involvement (eyes,

mouth, genitalia) - can scarTender, blistering skin and necrotic

epidermis – areas of denuded skinPositive Nikolsky sign (blisters extend

with skin pressure)

TEN / SJS - culprits

More than 100 drugs reported including ...PenicillinsSulfonamidesNSAIDS (including ibuprofen)Anticonvulsants AllopurinolAntiretrovirals .... and even paracetamolSusceptibility factors -

HIV, genetic susceptibility

TEN / SJS - Differential diagnoses

Erythema Multiforme - self limiting reaction triggered by infections e.g. HSV. Typical target lesions especially on acral sites. May involve mucosae.

Staphylococcal scalded skin syndrome (SSSS) - a localised infection with a toxigenic strain of S. Aureus triggers fever, redness of skin and easily ruptured blisters. Flexures often affected and mucosae uninvolved.

Autoimmune blistering disorders

TEN / SJS - investigations

Skin biopsy for histology and direct immunofluorescence (DIF)

H&E sections - basal or full thickness epidermal keratinocyte necrosis, supepidermal blistering (SSSS - the split is higher)

DIF - negative (rules out autoimmune disease)

TEN / SJS - management

Remove all possible culprit drugsSupportive care in ITU or high

dependency setting (skin failure)Careful fluid and electrolyte balanceAnalgesiaNon - adherent dressings / sheetsOphthalmology input Prevention and treatment of secondary infectionsConsider intravenous immunoglobulinFuture avoidance (including 1st degree relatives)

Drug induced Urticaria

Drug induced urticaria can occur with or without angioedema

Up to 3 weeks after first exposure (or minutes on re-challenge)

Types - Type 1 hypersensitivity (e.g. penicillin) -

can be associated with anaphylaxis Mast cell degranulation on first exposure

(e.g. NSAIDS, opiates) Angioedema without urticaria

(e.g. ACE inhibitors)

Drug Induced Urticaria - culprits

NSAIDSPenicillins CephalosporinsSulphonamidesACE inhibitorsCalcium channel

inhibitorsVaccinations

What is Erythroderma?

Intense and widespread reddening of the skin (more difficult to detect in asian / black skin)

> 90% Body Surface area involement

Often associated with exfoliation (exoliative dermatitis / exfoliative erythroderma)

Often results from exacerbation of a pre-existing skin disorder

Causes of Erythroderma

PsoriasisDermatitisCutaneous T- Cell

lymphomaDrugs

(red man syndrome) IdiopathicParaneoplastic

Erythroderma - management

Identify underlying cause (biopsy)Consider hospital admissionSupportive care (e.g. keep warm,

regular emollients, fluid balance, high protein diet)

Treat underlying disease (e.g. severe psoriasis - methotrexate or other systemics, dermatitis - topical or oral corticosteroids)

Avoid oral corticosteroids in severe psoriasis

Generalised Pustular Psoriasis

Rare form of psoriasis (patient presents with widespread sterile pustules on a background of red and tender skin)

Many have a background of chronic plaque psoriasis

Trigger factors include sudden withdrawal of oral (or potent topical) corticosteroids, infections, irritating topical preparations like tar or dithranol, pregnancy and drugs

Generalised Pustular Psoriasis

Pustule swab (exclude infectious causes)

Consider skin biopsyAdmissionFluid balance and supportive

careBland emollientsMay require systemic therapy

(e.g. oral retinoid such as acitretin, Methotrexate or anti-TNF therapy)

Pemphigus Vulgaris - clinical features

Rare autoimmune blistering disorder

The blisters are intra-epidermal (therefore easily ruptured)

IgG autoantibodies against a desmosomal protein

Usually presents initially with mucosal (oral, genital, conjunctival erosions) - difficulty eating

+/- skin erosions / blisters (and positive Nikolsky sign)

Pemphigus Vulgaris - treatment

Confirm diagnosis with skin biopsy (including direct IF)

Fatal before advent of oral corticosteroids

Likely to require admission for supportive care

Non adherent dressingsHigh dose oral steroids initially

(1 mg/kg/day)Prevention / treatment of infectionAdditional steroid sparing agent

usually needed

Bullous Pemphigoid - clinical features

Autoimmune blistering disorder, commoner in the elderly

Split is at the Basement Membrane zone (deeper than in PV)

Crops of tense fluid filled blisters, often with surrounding erythema

ItchyCan be localised or widespreadOral mucosal involvement less

frequent than PVUsually less severe than PV

Bullous Pemphigoid -treatment

Confirm diagnosis with skin biopsy (including direct and indirect IF)

Biopsy confirmation less probable if patient already on oral corticosteroids

Admission not always necessaryTreatment – usually oral +/- topical

corticosteroids (reducing course commencing around 0.5 mg/kg/day)

Attention to dressingsMay need steroid sparing agent

(e.g. dapsone, azathioprine)

Eczema herpeticum

Herpes simplex infections can be more severe and extensive in patients with underlying skin disease (e.g. eczema)

Systemic antivirals +/- antibiotics needed

May need admission Ophthalmology input if eyelids

involved or eyes feel gritty

Learning points

Pause before you prescribe – is this drug really necessary?

Warning signs in severe drug reaction (e.g. fever, mucosal involvement, blistering, tenderness)

Caution with oral corticosteroids in psoriasis (abrupt withdrawal can precipitate generalised pustular psoriasis)

When you need us.....

On call team (via switchboard on 01932 872000) if admission needed

Call dermatology (particularly if admission avoidable but urgent treatment needed)

SPH 01932 723720 01932 722234 01932 722748

Ashford 01784 884352

…and a happy ending……

Any questions?